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    <head>
        <title>Employment Application Form</title>
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    <body onload="PrintWindow();">
        <div class="row">
            <b>PRIVATE &amp; CONFIDENTIAL</b><br/>
            <img src="Images/Keppel-Land-Thinking-Unboxed.png"  />
        </div>
        
        <div style="text-align:center">
            <h1>EMPLOYMENT APPLICATION FORM</h1>
        </div>
        
        <xsl:for-each select="NewDataSet/Table8">
            <table class="layout">
                <tr>
                    <td class="l nowrap">Position Applied for <xsl:value-of select="JobTitle"/></td>
                </tr>
            </table>
        </xsl:for-each>
        
        <xsl:for-each select="NewDataSet/Table">
            <table class="layout">
                <tr>
                    <td class="l nowrap">How did you come to know about this vacancy?</td>
                    <td width="100%">
                        <xsl:value-of select="VacancyMedium"/>
                        <xsl:if test="AgencyName != ''">(<xsl:value-of select="AgencyName"/>)</xsl:if>
                    </td>
                </tr>
            </table>
            <p></p>
            <hr/>
            <table class="layout">
                <tr>
                    <td colspan="2" class="h">PERSONAL PARTICULARS</td>
                </tr>
                <tr>
                    <td colspan="2">&#160;</td>
                </tr>
                <tr>
                    <td width="20%" class="l">Saluation</td>
                    <td><xsl:value-of select="Saluation"/></td>
                </tr>
<!-- 
GivenName           
Surname
NameFormat
DisplayName
ChineseCharacter 

Given Name
Surname
Name Format
Display Name
Chinese Character

-->                
                <tr>
                    <td class="l">Given Name</td>
                    <td><xsl:value-of select="GivenName"/></td>
                </tr>
                <tr>
                    <td class="l">Surname</td>
                    <td><xsl:value-of select="Surname"/></td>
                </tr>
                <tr>
                    <td class="l">Display Name</td>
                    <td><xsl:value-of select="DisplayName"/></td>
                </tr>
                <tr>
                    <td class="l">Chinese Character</td>
                    <td><xsl:value-of select="ChineseCharacter"/></td>
                </tr>
<!--
Identity No	        Identity Type
Issuing Date	
Passport No	
Citizenship	
Place of Birth

IdentityNo
    IdentityType
IssuingDate
PassportNo
Citizenship
PlaceofBirth

-->
                <tr>
                    <td class="l nowrap">Identity No (Identity Type)</td>
                    <td><xsl:value-of select="IdentityNo"/> (<xsl:value-of select="IdentityType"/>)</td>
                </tr>
                <tr>
                    <td class="l">Issuing Date</td>
                    <td><xsl:value-of select="IssuingDate"/></td>
                </tr>
                <tr>
                    <td class="l">Passport No</td>
                    <td><xsl:value-of select="PassportNo"/></td>
                </tr>
                <tr>
                    <td class="l">Citizenship</td>
                    <td><xsl:value-of select="Citizenship"/></td>
                </tr>
                <tr>
                    <td class="l">Place of Birth</td>
                    <td><xsl:value-of select="PlaceofBirth"/></td>
                </tr>
                <tr>
                    <td class="l nowrap">Block/House No, UnitNo</td>
                    <td>
                        <xsl:if test="BlockHouseNo != ''">
                            <xsl:value-of select="BlockHouseNo"/>, 
                        </xsl:if>
                        
                        <xsl:choose>
                            <xsl:when test="Floor">#<xsl:value-of select="format-number(Floor, '00')"/>-</xsl:when>
                        </xsl:choose><xsl:value-of select="UnitNo"/>
                    </td>
                </tr>
                
<!--
StreetName
BuildingName
PostalCode
Country
City

Street Name
Building Name
Postal Code
Country
City


-->
<tr>
    <td class="l">Street Name</td>
    <td><xsl:value-of select="StreetName"/></td>
</tr>
<tr>
    <td class="l">Building Name</td>
    <td><xsl:value-of select="BuildingName"/></td>
</tr>
<tr>
    <td class="l">Postal Code</td>
    <td><xsl:value-of select="PostalCode"/></td>
</tr>
<tr>
    <td class="l">Country</td>
    <td><xsl:value-of select="Country"/></td>
</tr>
<tr>
    <td class="l">City</td>
    <td><xsl:value-of select="City"/></td>
</tr>
                
                
                <!--
State
Contact No (M)
Contact No (H)
Driving License Class
Total No. Of Years Working Experience

State
ContactNoM
ContactNoH
DrivingLicenseClass
TotalNo.OfYearsWorkingExperience

                -->
                
<tr>
    <td class="l">State</td>
    <td><xsl:value-of select="State"/></td>
</tr>
<tr>
    <td class="l">Contact No (M)</td>
    <td><xsl:value-of select="ContactNoM"/></td>
</tr>
<tr>
    <td class="l">Contact No (H)</td>
    <td><xsl:value-of select="ContactNoH"/></td>
</tr>
<tr>
    <td class="l">Email</td>
    <td><xsl:value-of select="EmailAddress"/></td>
</tr>
<tr>
    <td class="l">Driving License Class</td>
    <td><xsl:value-of select="DrivingLicenseClass"/></td>
</tr>
<tr>
    <td class="l nowrap">PDPA consent granted on</td>
    <td><xsl:value-of select="PDPAAcknowledgment"/></td>
</tr>
            </table>
        </xsl:for-each>
        
        <!--
        
        EDUCATION QUALIFICATION (2)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <table class="layout">
            <tr>
                <th colspan="6" class="h">EDUCATION QUALIFICATION</th>
            </tr>
            <tr>
                <td colspan="2">&#160;</td>
            </tr>
            <tr>
                <th width="16%">Qualification Obtained</th>
                <th width="16%">Major/Specialization</th>
                <th width="16%">Institution Attended</th>
                <th width="16%">Country of Study</th>
                <th width="16%">Duration From</th>
                <th width="16%">Duration To</th>
            </tr>
            <xsl:choose>
                <xsl:when test="NewDataSet/Table1">
                    <xsl:for-each select="NewDataSet/Table1">
                        <tr>
                            <td><xsl:value-of select="Qualification"/></td>
                            <td><xsl:value-of select="MajorSpecialization"/></td>
                            <td><xsl:value-of select="Institution"/></td>
                            <td><xsl:value-of select="Country"/></td>
                            <td><xsl:value-of select="DurationFrom"/></td>
                            <td><xsl:value-of select="DurationTo"/></td>
                        </tr>
                    </xsl:for-each>
                </xsl:when>
                <xsl:otherwise>
                    <tr>
                        <td colspan="6">No records</td>
                    </tr>
                </xsl:otherwise>
            </xsl:choose>
            
        </table>
        


        <!--
        
        PROFESSIONAL MEMBERSHIP (3)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <table class="layout">
            <thead>
                <tr>
                    <th colspan="5" class="h">PROFESSIONAL MEMBERSHIP</th>
                </tr>
                <tr>
                    <td colspan="2">&#160;</td>
                </tr>
                <tr>
                    <th width="24%">Institution</th>
                    <th width="24%">Certification</th>
                    <th width="24%">Date Attained</th>
                    <th width="24%">Position Held</th>
                </tr>
            </thead>
            <tbody>
                <xsl:choose>
                    <xsl:when test="NewDataSet/Table3">
                        <xsl:for-each select="NewDataSet/Table3">
                            <tr>

                                <td><xsl:value-of select="Institution"/></td>
                                <td><xsl:value-of select="Certification"/></td>
                                <td><xsl:value-of select="DateAttained"/></td>
                                <td><xsl:value-of select="PositionHeld"/></td>
                            </tr>
                        </xsl:for-each>
                    </xsl:when>
                    <xsl:otherwise>
                        <tr>
                            <td colspan="5">No records</td>
                        </tr>
                    </xsl:otherwise>
                </xsl:choose>
            </tbody>
        </table>
        
        
        <!--
        
        LANGUAGE PROFICIENCY (4)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <table class="layout">
            <thead>
                <tr>
                    <th colspan="3" class="h">LANGUAGE PROFICIENCY</th>
                </tr>
                <tr>
                    <td colspan="2">&#160;</td>
                </tr>
                <tr>
                    <th width="33%">Language</th>
                    <th width="33%">Ability</th>
                    <th width="33%">Proficiency</th>
                </tr>
            </thead>
            <tbody>
                <xsl:choose>
                    <xsl:when test="NewDataSet/Table2">
                        <xsl:for-each select="NewDataSet/Table2">
                            <tr>
                                <!-- 
                                Language
                                Ability
                                Proficiency
                                -->
                                <td><xsl:value-of select="Language"/></td>
                                <td><xsl:value-of select="Ability"/></td>
                                <td><xsl:value-of select="Proficiency"/></td>
                            </tr>
                        </xsl:for-each>
                    </xsl:when>
                    <xsl:otherwise>
                        <tr>
                            <td colspan="3">No records</td>
                        </tr>
                    </xsl:otherwise>
                </xsl:choose>
            </tbody>
        </table>
        
        <!--
        
        NATIONAL SERVICE (5)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <xsl:for-each select="NewDataSet/Table5">
        <table class="layout">
            <tr>
                <td colspan="2" class="h">NATIONAL SERVICE</td>
            </tr>
            <tr>
                <td colspan="2">&#160;</td>
            </tr>
<!--
National Service
Service Type
NS Status

Vocation
Rank
ORD Date

NationalService	ServiceType	NSStatus	Vocation	Rank	ORDDate
Completed	Republic of Singapore Army	NSStatus	Vocation	3rd Sergeant	27/01/2011

-->
            <tr>
                <td width="20%" class="l">NSF Status</td>
                <td><xsl:value-of select="NationalService"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Service Type</td>
                <td><xsl:value-of select="ServiceType"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Vocation</td>
                <td><xsl:value-of select="Vocation"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Rank</td>
                <td><xsl:value-of select="Rank"/></td>
            </tr>
            <tr>
            <td width="20%" class="l">Enlistment Date</td>
                <td><xsl:value-of select="EnlistmentDate"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">ORD Date</td>
                <td><xsl:value-of select="ORDDate"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Reservist Status</td>
                <td><xsl:value-of select="ReservistStatus"/></td>
            </tr>
            <tr>
                <td width="20%" class="l" style="white-space:nowrap;">Reservist Service Type</td>
                <td><xsl:value-of select="RSServiceType"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Reservist Vocation</td>
                <td><xsl:value-of select="RSVocation"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Reservist Rank</td>
                <td><xsl:value-of select="RSRank"/></td>
            </tr>
            <tr>
                <td width="20%" class="l">Reservist Completion Date</td>
                <td><xsl:value-of select="RSCompletionDate"/></td>
            </tr>
            
        </table>
        </xsl:for-each>
        
        
        <!--
        
        EMPLOYMENT HISTORY (6)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        
        <p></p>
        <hr/>
        <table class="layout" style="page-break-before:always" >
            <tr>
                <td colspan="6" class="h">EMPLOYMENT HISTORY</td>
            </tr>
            <tr>
                <td colspan="6">&#160;</td>
            </tr>
            <xsl:for-each select="NewDataSet/Table4">
                <tr>
                    <td width="15%" valign="top">
                        <strong>Employer</strong>
                    </td>
                    <td width="35%" valign="top">
                        <xsl:value-of select="Employer"/>
                    </td>
                    <td width="15%" valign="top" style="white-space:nowrap;">
                        <strong>Nature of Business</strong>
                    </td>
                    <td width="35%" colspan="3" valign="top">
                        <xsl:value-of select="Nature"/>
                    </td>
                </tr>
                <tr>
                    <td valign="top" style="white-space:nowrap;">
                        <strong>Period of Service From</strong>
                    </td>
                    <td valign="top">
                        <xsl:value-of select="PeriodFrom"/>
                    </td>
                    <td valign="top">
                        <strong>To</strong>
                    </td>
                    <td colspan="3">
                        <xsl:value-of select="PeriodTo"/>
                    </td>
                </tr>
                <tr>
                    <td valign="top" style="white-space:nowrap;">
                        <strong>Starting Position</strong>
                    </td>
                    <td valign="top">
                        <xsl:value-of select="StartingPosition"/>
                    </td>
                    <td valign="top" style="white-space:nowrap;">
                        <strong>Starting Basic Salary</strong>
                    </td>
                    <td colspan="3">
                        <xsl:value-of select="StartingBasicSalary"/>
                    </td>
                </tr>
                <tr>
                    <td valign="top" style="white-space:nowrap;">
                        <strong>Current Position</strong>
                    </td>
                    <td valign="top">
                        <xsl:value-of select="CurrentPosition"/>
                    </td>
                    <td valign="top" style="white-space:nowrap;">
                        <strong>Current Basic Salary</strong>
                    </td>
                    <td colspan="3">
                        <xsl:value-of select="CurrentBasicSalary"/>
                    </td>
                </tr>
                <tr>
                    <td valign="top">
                        <strong>Allowances</strong>
                    </td>
                    <td valign="top">
                        <xsl:value-of select="Allowances"/>
                    </td>
                    <td width="10%" valign="top">
                        <strong>AWS</strong>
                    </td>
                    <td width="15%" valign="top">
                        <xsl:value-of select="AWS"/>
                    </td>
                    <td width="10%" valign="top">
                        <strong>Bonus</strong>
                    </td>
                    <td width="15%" valign="top">
                        <xsl:value-of select="Bonus"/>
                    </td>
                </tr>
                <tr>
                    <td valign="top">
                        <strong>Job Duties</strong>
                    </td>
                    <td valign="top" colspan="5" class="wrap">
                        <xsl:value-of select="JobDuties"/>
                    </td>
                </tr>
                <tr>
                    <td valign="top" style="white-space:nowrap;">
                        <strong>Reason for Leaving</strong>
                    </td>
                    <td valign="top" colspan="5">
                        <xsl:value-of select="ReasonLeaving"/>
                    </td>
                </tr>
                
                <xsl:if test="position() != last()">
                <tr>
                    <td colspan="6">
                        <hr noshade="" size="1" />
                    </td>
                </tr>
                </xsl:if>
                
            </xsl:for-each>
        </table>
        
        
        <!--
        
        AWARDS (7)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <table class="layout">
            <tr>
                <th colspan="3" class="h">AWARDS / SPECIAL ACHIEVEMENTS / COMMENDATIONS</th>
            </tr>
            <tr>
                <td colspan="3">&#160;</td>
            </tr>
            <tr>
                <th width="32%">Description of Award</th>
                <th width="32%">Awarding Body</th>
                <th width="32%">Year Awarded</th>

            </tr>
            <xsl:choose>
                <xsl:when test="NewDataSet/Table7">
                    <xsl:for-each select="NewDataSet/Table7">
                        <tr>
                            <td><xsl:value-of select="Description"/></td>
                            <td><xsl:value-of select="AwardingBody"/></td>
                            <td><xsl:value-of select="DateAwarded"/></td>
                        </tr>
                    </xsl:for-each>
                </xsl:when>
                <xsl:otherwise>
                    <tr>
                        <td colspan="3">No records</td>
                    </tr>
                </xsl:otherwise>
            </xsl:choose>
            
        </table>

        
        <!--
        
        EMPLOYMENT EXPECTION (8)
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <table class="layout">
            <tr>
                <th colspan="4" class="h">EMPLOYMENT EXPECTION</th>
            </tr>
            <tr>
                <td colspan="4">&#160;</td>
            </tr>
            <tr>
                <th width="22%">No of Year of Work Exp</th>
                <th width="22%">Period of Notice (Mths)</th>
                <th width="22%">Approx Availability Date</th>
                <th width="22%">Expected Salary</th>

            </tr>
            <xsl:choose>
                <xsl:when test="NewDataSet/Table">
                    <xsl:for-each select="NewDataSet/Table">
                        <tr>
                            <td><xsl:value-of select="TotalNoOfYearsWorkingExperience"/></td>
                            <td><xsl:value-of select="PeriodofNotice"/></td>
                            <td><xsl:value-of select="ApproxAvailabilityDate"/></td>
                            <td><xsl:value-of select="ExpectedMonthlyBasicSalary"/></td>
                        </tr>
                    </xsl:for-each>
                </xsl:when>
                <xsl:otherwise>
                    <tr>
                        <td colspan="4">No records</td>
                    </tr>
                </xsl:otherwise>
            </xsl:choose>
            
        </table>
        
        <!--
        
        FURTHER INFORMATION
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <p></p>
        <hr/>
        <xsl:for-each select="NewDataSet/Table6">
        <table class="layout">
            <tr>
                <td colspan="3" class="h">FURTHER INFORMATION</td>
            </tr>
            <tr>
                <td colspan="3">&#160;</td>
            </tr>
            
            <!--
Would you consider relocation if there is an overseas working opportunity?
Have you been or are you suffering from any physical disability or medical condition that requires you to be on medication for prolonged period (includes colour blindness, hearing loss, hypertension, diabetes and asthma)? 
Have you ever been detained, charged or convicted by a Court of Law in any country?  
Have you, in the last 10 years, been involved in a petition under any bankruptcy laws in any jurisdiction filed against you?  

            -->
            <tr>
                <td width="3%" class="l">1</td>
                <td>Would you consider relocation if there is an overseas working opportunity?</td>
                <td width="5%"><xsl:value-of select="Q1"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <tr>
                <td class="l">2</td>
                <td class="wrap">
                    Have you been or are you suffering from any disease / medical condition / mental disorder or physical impairment? (e.g. Hypertension, diabetes, asthma, colour blindness, hearing loss, fear of heights/depths or flat feet)
                </td>
                <td><xsl:value-of select="Q2"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo2Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            <tr>
                <td class="l">3</td>
                <td>Have you ever been detained, charged and/or convicted by a court of law in any country?  </td>
                <td><xsl:value-of select="Q3"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo3Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <tr>
                <td class="l">4</td>
                <td>Has any bankruptcy action every been taken against you?</td>
                <td><xsl:value-of select="Q4"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo4Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <!--
            Have you ever been treated for drug or alcohol abuse?  
Have you been dismissed or suspended by any employer?  
Have you ever applied for any position in any company within the Keppel Group?  
Do you have any friends or relatives working in any company within the Keppel Group? 
            -->
            <tr>
                <td class="l">5</td>
                <td>Have you ever been treated for drug and/or alcohol abuse?  </td>
                <td><xsl:value-of select="Q5"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo5Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <tr>
                <td class="l">6</td>
                <td>Have you been dismissed and/or suspended from employment?  </td>
                <td><xsl:value-of select="Q6"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo6Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <tr>
                <td class="l">7</td>
                <td>Have you ever applied for any position in Keppel Group of Companies within the last six months?  </td>
                <td><xsl:value-of select="Q7"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo7Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <tr>
                <td class="l">8</td>
                <td>Do you have any family members, relatives and/or friends working in Keppel Group of Companies? </td>
                <td><xsl:value-of select="Q8"/></td>
            </tr>
            <tr>
                <td></td>
                <td><xsl:value-of select="FurtherInfo8Details"/></td>
            </tr>
            <tr>
                <td>&#160;</td>
            </tr>
            
            <tr>
                <td class="l">9</td>
                <td>Is there anything you wish to add to assist you in your application or which you may like to highlight. </td>
                <td><xsl:choose>
                        <xsl:when test="Q9 = ''">No</xsl:when>
                        <xsl:otherwise>Yes</xsl:otherwise>
                    </xsl:choose></td>
            </tr>
            <tr>
                <td class="l"></td>
                <td colspan="2" class="wrap">
                    <xsl:value-of select="Q9"/>
                </td>
            </tr>
        </table>
        </xsl:for-each>

        <!--
        
        PDPA DECLARATION
        
        ^^^^^^^^^^^^^^^^^^^^^^^ -->
        <!-- 
            PDPA Declaration
        -->
        <p></p>
        <hr/>
        <xsl:for-each select="NewDataSet/Table">
            
            <table class="layout">
                <tr>
                    <td colspan="2" class="h">CONSENT</td>
                </tr>
                <tr>
                    <td colspan="2">&#160;</td>
                </tr>
                <tr>
                    <td colspan="2" class="wrap">
<p style="text-align:justify;">
The personal data you provide herein will be collected, use and disclosed by or on behalf of Keppel Land Group to determine or investigate your suitability, eligibility or qualifications for employment and manage your application for employment with any company within the Keppel Land Group, including identifying you as a potential candidate for future suitable positions within the Keppel Land Group and/or notifying you of any such positions. In addition, a company within the Keppel Land Group may collect from other members of the  Keppel Land Group, a third party organisation (including background screening agencies, service providers and credit reference agencies) or publicly available sources, additional personal data, for the purposes described above. 
</p>

<p style="text-align:justify;">
All such personal data may be disclosed to other companies within the Keppel Land Group and to third party organisations providing administrative or other services, within and outside Singapore, for the purposes as described above. 
</p>
   
<p style="text-align:justify;">
Keppel Land Group will ensure that your personal data is protected in accordance with the Singapore Personal Data Protection Act 2012 and other applicable personal data protection laws and legislation.
</p>
   
<p style="text-align:justify;">
By entering your data into this form, you: (i) consent to the collection, processing, use, and disclosure of your personal data as outlined in this notice; (ii) expressly permit Keppel Land Group and its representatives to share this notice with third parties and third party organisations; (iii) hereby authorise all such persons to disclose to Keppel Land Group Companies any of your personal data reasonably requested by Keppel Land Group for one or more of the specific purposes as described above.
</p>
   
<p style="text-align:justify;">
Where you have provided personal data of a third party in this form, you represent and warrant that you have obtained consent from such third party that his personal data will be collected, used and disclosed by or on behalf of Keppel Land  Group  to contact him for reference and emergency contact purposes and that all such personal data may be disclosed to other companies within the Keppel Land Group and to third party organisations providing administrative or other services, within and outside Singapore, for such purposes.
</p>
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                    <td colspan="2" class="h">DECLARATION</td>
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                    <td colspan="2">&#160;</td>
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<p style="text-align:justify;">
I declare that the above information and documents attached hereto are true to the best of my knowledge and belief, and that I have not wilfully suppressed any material facts. I understand that any false answers or statements made by me on this application or any supplement thereto, or in connection with the above investigation, will be sufficient grounds for immediate termination of my employment.
</p>

<p style="text-align:justify;">
I further voluntarily give the Keppel Land Group and any of its companies the right to check on my past employment and activities, agree to co-operate in such background checks, and release from all liability or responsibility all persons, companies or corporations supplying such information.
</p>
                  
Yes, I agree.&#160;<img src="Images/Checkbox.png" style="vertical-align: middle;" />
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            <td>______________________________</td>
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            <td class="text-right">______________________________</td>
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            <td>Signature of Applicant</td>
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            <td class="text-right">Date</td>
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